: Tuberculosis (TB) and poverty are inextricably linked. Catastrophic costs of TB illness drive TB-affected households into worsening impoverishment and hamper treatment success. The WHO’s End TB Strategy recommends social protection for TB-affected households to mitigate financial shock and improve TB outcomes. This scoping review maps the landscape of social protection interventions for people with TB and their households in low- and middle-income countries with high TB burden. A systematic search of Medline, Embase, PubMed, and Web of Science for relevant articles was performed, supplemented with a gray literature search of key databases. Articles were included if they described social protection available to people with TB and TB-affected households in a low- or middle-income country. Data were synthesized in tabular form, and descriptive narrative outlined the successes and challenges of the social protection interventions identified. The search identified 33,360 articles. After abstract screening, 74 articles underwent full text screening, and 49 were included in the final analysis. Forty-three types of social protection were identified, of which 24 were TB specific (i.e., only people with TB were eligible). Varying definitions were used to describe similar social protection interventions, which limited cross-study comparison. Intervention successes included acceptability and increased financial autonomy among recipients. Challenges included delays in intervention delivery and unexpected additional bank transfer fees. A wide range of acceptable social protection interventions are available, with cash transfer schemes predominating. Use of standardized definitions of social protection interventions would facilitate consolidation of evidence and enhance design and implementation in future.

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6–38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32–5.30), previous hospitalization (OR 2.15; 95%CI 1.25–3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51–7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83–5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72–8.22), which is unconfirmed in the literature so far.

Background: Frequent antibiotic prescribing in departments with high infection risk like orthopedics prominently contributes to the global increase of antibiotic resistance. However, few studies present antibiotic prescribing patterns and trends among orthopedic inpatients. Aim: To compare and present the patterns and trends of antibiotic prescription over 10 years for orthopedic inpatients in a teaching (TH) and a non-teaching hospital (NTH) in Central India. Methods: Data from orthopedic inpatients (TH-6446; NTH-4397) were collected using a prospective cross-sectional study design. Patterns were compared based on the indications and corresponding antibiotic treatments, mean Defined Daily Doses (DDD)/1000 patient-days, adherence to the National List of Essential Medicines India (NLEMI) and the World Health Organization Model List of Essential Medicines (WHOMLEM). Antibiotic prescriptions were analyzed separately for the operated and the non-operated inpatients. Linear regression was used to analyze the time trends of antibiotic prescribing; in total through DDD/1000 patient-days and by antibiotic groups. Results: Third generation cephalosporins were the most prescribed antibiotic class (TH-39%; NTH-65%) and fractures were the most common indications (TH-48%; NTH-48%). Majority of the operated inpatients (TH-99%; NTH-97%) were prescribed pre-operative prophylactic antibiotics. The non-operated inpatients were also prescribed antibiotics (TH-40%; NTH-75%), although few of them had infectious diagnoses (TH-8%; NTH-14%). Adherence to the NLEMI was lower (TH-31%; NTH-34%) than adherence to the WHOMLEM (TH-65%; NTH-62%) in both hospitals. Mean DDD/1000 patient-days was 16 times higher in the TH (2658) compared to the NTH (162). Total antibiotic prescribing increased over 10 years (TH-β = 3.23; NTH-β = 1.02). Conclusion: Substantial number of inpatients were prescribed antibiotics without clear infectious indications. Adherence to the NLEMI and the WHOMLEM was low in both hospitals. Antibiotic use increased in both hospitals over 10 years and was higher in the TH than in the NTH. The need for developing and implementing local antibiotic prescribing guidelines is emphasized.

India has one of the world’s highest burdens of antimicrobial resistance (AMR). Broad-spectrum antibiotics are routinely and empirically initiated in surgery and orthopedic departments, contributing to the AMR. This study aimed to explore the capabilities, opportunities and motivation that influence antibiotic prescribing practices of general and orthopedic surgeons in Central India. This qualitative study was guided by the Capability, Opportunity, Motivation-Behavior model (COM-B) and the Theoretical Domains Framework (TDF). Semi-structured interviews were conducted until redundancy was achieved, including 15 general and orthopedic surgeons in three private-sector hospitals in Ujjain district. Questions were formulated to explore how decisions about antibiotic prescribing are made, and surgeons´ perceptions of antibiotic use, AMR and potential solutions. Manifest and latent content analysis was used. Three main themes were revealed: (1) Antibiotic prescribing decision is a multifactorial process influenced by environmental and sociocultural factors; (2) Infection prevention and control (IPC), diagnostics and treatment need strengthening; (3) AMR is a social problem that requires a collective effort. Participants emphasized the critical role of environmental (e.g., dusty rural setting) and sociocultural factors (e.g., patients’ socioeconomic status) in influencing antibiotic prescribing decisions. Prescribing practices were mostly empirical and varied between participants. Junior practitioners expressed a strong desire for regulation, guidelines, feedback and improvement, whereas senior practitioners were more confident in their prescribing. Doctors expressed frustration and hopelessness when treating resistant infections and recalled the significant contribution of the COVID-19 pandemic to inappropriate antibiotic use. The AMR problem in India was perceived as a broader social issue requiring collective action. Proposed solutions included strengthening IPC and diagnostic practices, developing contextualized antibiotic prescribing guidelines, stricter regulations on antibiotic use, and public education. Antibiotic prescribing decisions are multifactorial and context-specific, strongly impacted by prescribers’ experiences and environmental and sociocultural factors. Our findings could inform future interventions to improve antibiotic use in Central India and beyond.

Background: Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs. Methods: Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days. Results: Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan. Conclusions: This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.

Orthopedic surgeries contribute to overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably depending on geographical location (1.6–38%); however, there is a lack of a national SSI surveillance system.. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the Centre for Disease Control and Prevention’s guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed to identify risk factors for SSIs. Overall, 7.6% patients developed SSIs over three years. Out of 68 samples sent for culture and susceptibility testing, 22% were culture positive. The most common SSI-causing microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32–5.30), previous hospitalization (OR 2.15; 95%CI 1.25–3.69), prescription of antibiotics during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51–7.00) and postoperative length of stay >15 days (OR 3.30; 95%CI 1.83–5.95) were identified as significant risk factors for orthopedic SSIs. Additionally, a preoperative shower significantly increased the risk of SSIs (OR 4.73; 95% CI 2.72–8.22), which is unconfirmed in the literature so far.